Chapter |4|

The psychology of pain: models and targets

for comprehensive assessment
Gordon J.G. Asmundson, Lydia Gomez-Perez, Ashley A. Richter and R. Nicholas Carleton

important features of a historical model that provided the

CHAPTER CONTENTS
foundation for contemporary biopsychosocial approaches
Overview 35 to understanding pain, selectively highlight important
Pain and chronic pain defined 35 cognitive constructs and pain behaviours as well as envir-
onmental influences, and conclude with a summary of
Models pertinent to understanding pain 36
important considerations in assessment planning and
Cognitive constructs 37 case conceptualization. This approach is predicated on
Behavioural constructs 39 the position that assessment and case conceptualization
Environmental influences 41 should be a conceptually driven process (Asmundson &
Hadjistavropoulos 2006; Taylor & Asmundson 2004); as
Key considerations in assessment and case
conceptualization 42 such, empirically supported theoretical constructs and
applications form the foundation upon which assessment,
Conclusion 43 case conceptualization and subsequent treatment plans
are built. Throughout we refer to current empirical findings
LEARNING OBJECTIVES and, as appropriate, incorporate examples to illustrate
salient points.
On completing this chapter readers will have an
understanding of the following:
1. The distinction between pain and chronic pain.
PAIN AND CHRONIC PAIN DEFINED
2. Gate control theory.
3. Biopsychosocial models of pain.
The traditional biomedical model of pain dates back to
4. Cognitive constructs associated with beliefs, mood, Descartes (15961650), who suggested that pain is a
anxiety and fear. sensory experience resulting from stimulation of specific
5. Behavioural constructs related to avoidance, activity noxious receptors, usually from physical damage due to
limitation, coping behaviour, pain and suicide. injury or disease. Consistent with Cartesian dualism (i.e.
6. Environmental influences of family, culture and the idea that mind and body are non-overlapping entities),
ethnicity, socioeconomic factors and work. the model is both reductionistic (i.e. all disease is directly
linked to specific physical pathology) and exclusionary
(i.e. social, psychological, behavioural mechanisms of
OVERVIEW illness are not of primary importance). Applications
of the traditional biomedical model to diagnosis, assess-
In this chapter we review the current state of knowledge ment and treatment are generally straightforward. Physical
regarding the psychology of pain as it can be applied pathology would be confirmed by data from objective tests
to assessment planning and case conceptualization. We of physical damage, and interventions would then be
provide definitions of pain and chronic pain, summarize directed toward rectifying the damage and associated

2014 Elsevier Ltd.

35
Section | 1 | Overview: what is pain?
limitations in physical functioning. The experience of pain
would not be viewed as significant but, rather, as a second-
ary reaction to or symptom of physical damage that would
diminish with healing.
Pain is now understood to involve more than a pure sen-
sory experience arising from physical injury or other
pathology. Over the past half century a number of pain
models that incorporate biological as well as psychological
(e.g. perception, cognition, affect), behavioural (e.g. avoid-
ance) and social (e.g. cultural) factors have been proposed.
These models, described in more detail below, have
dramatically improved the understanding of pain and the
ability to assess and effectively intervene in cases where it
is intense, unremitting or both intense and unremitting.
Pain is currently defined as a complex perceptual phenom-
enon that involves a number of dimensions, including, but
not limited to, intensity, quality, time course and personal
meaning (Merskey & Bogduk 1994). It is adaptive in the
short term, facilitating the ability to identify, respond to
and resolve physical pathology or injury. Unfortunately, a
significant number of people experience pain for periods that
substantially exceed expected times for physical healing (e.g.
Waddell 1987). When pain persists for 3 months or longer, it
is considered chronic (e.g. International Association for the
Study of Pain (IASP) 1986) and, while not necessarily mal-
adaptive (Asmundson et al 1998; Turk & Rudy 1987), often
leads to physical decline, limited functional ability and emo-
tional distress. These pain experiences are also associated
with an increased probability of experiencing comorbid
psychopathology (McWilliams et al 2003; for review, see
Asmundson & Katz 2009), inappropriate use of medical ser-
vices, reduced work performance or absenteeism, and high
cost insurance claims (Spengler et al 1986; Stewart et al
2003). Translated into a dollar value, common chronic pain
conditions cost the USA and Canada, respectively, approxi-
mately US$60 billion and CAN$6 billion dollars annually.
MODELS PERTINENT TO
UNDERSTANDING PAIN
There are several contemporary pain models that are impor-
tant in the context of assessment and case conceptualiza-
tion. These models are similar in that they all recognize
the interplay between biological, psychological and socio-
cultural factors in the pain experience. Below we highlight
one model of considerable historical significance as well
as primary features of various contemporary biopsychoso-
cial models. Detailed descriptions of the social influences
on pain are provided by Craig in this volume (Chapter 3).
Gate control theory
Melzack and colleagues seminal papers on the gate control
theory of pain (Melzack & Casey 1968; Melzack & Wall
36
1965) are frequently cited as the first to integrate biological
and psychological mechanisms of pain within the context
of a single model. Melzack & Wall (1965) suggested that
the passage of ascending nociceptive (pain) information
from the body to the brain was controlled by a hypothetical
gating mechanism within the dorsal horn of the spinal
cord. The gating mechanism works as follows. Excitation
along the large-diameter, myelinated fibres of the spinal
cord closes the gate, whereas excitation along the small-
diameter, unmyelinated fibres opens the gate. Transmis-
sions about current cognition and mood descending from
the brain to the gating mechanism also influence whether
the gate is closed or opened. In short, the summation of
information travelling along the different types of ascend-
ing fibres from the body with that travelling on descending
fibres from the brain determines whether the gate is
open or closed and, thereby, influences the perception of
pain. Melzack & Casey (1968) further proposed that three
different neural networks (i.e. sensorydiscriminative,
motivationalaffective and cognitiveevaluative) influence
the modulation of sensory input. The addition of these net-
works to the model allowed for perceptual information
regarding the location, magnitude, and spatiotemporal
properties of the noxious stimulus, motivational tendency
toward escape or attack, and cognitive information based
on analysis of multimodal information, past experience,
and probability of outcome of different response strategies
(pp 427428).
Time and empirical effort have led to advances in under-
standing the anatomy and structure of the gating mechanism
proposed by Melzack and Wall (Price 2000; Wall 1996),
as well as to elaborations of the neural network model
(Melzack 1999; Melzack & Katz 2004; please refer to
Chapter 6). Notwithstanding, the gate control theory chal-
lenged the primary assumptions of the traditional biomed-
ical models. Rather than being exclusively conceptualized
as sensation arising from physical damage, the experience
of pain came to be viewed as a combination of both patho-
physiology and psychological factors. As such, pain as well
as pain-related cognitions and mood were no longer viewed
as secondary reactions to physical damage. Instead, the path-
ophysiology of pain was conceptualized as having a recipro-
cal influence on cognitions and mood, and vice versa. It is
this foundation from which contemporary biopsychosocial
models emerged.
Biopsychosocial models
The biopsychosocial approach holds that the experience of
pain is determined by the interaction between biological,
psychological (e.g. cognition, behaviour, mood) and social al
number of specific biopsychosocial
(e.g. cultural) factors. A n
models have been proposed over the past 35 years, includ-
ing several behaviourally based models (Fordyce 1976;
Fordyce et al 1982), as well as the more comprehensive cog-
nitivebehavioural Glasgow (Waddell 1987; Waddell et al
 The psychology of pain: models and targets for comprehensive assessment
1984) and biobehavioural (Turk 2002; Turk & Flor 1999;
Turk et al 1983) models. Detailed descriptions of these
models of pain are provided elsewhere (e.g. Asmundson
et al 2004a; Asmundson & Wright 2004).
Despite differences with respect to specificity regarding
behavioural and cognitive influences on pain, all of the
biopsychosocial models share a common focus the
focus is not on disease per se but on illness, where illness
is viewed as a type of behaviour (Parsons 1951). The con-
cept of illness behaviour (Mechanic 1962) implies that
individuals may differ in perception of and response to
bodily sensations and changes (e.g. pain, nausea, heart
palpitations), and that these differences can be under-
stood in the context of psychological and social processes.
For example, whereas one person may perceive pain as
indicative of a potentially serious malady and solicit reas-
surances or assistance from others in even the most rudi-
mentary of daily activities, another person may perceive
similar pain as discomforting but harmless and work
through the discomfort. Illness behaviour is considered
a dynamic process, with the role of biological, psycholog-
ical and social factors changing in relative importance as
the condition evolves. While a condition may be initiated
by biological factors, such as physical injury or pathology,
the psychological and social factors may come to play a
primary role in maintenance and exacerbation; indeed,
the focus often shifts from pain to significant concern
and anxiety about personal health and well-being (see,
for example, Hadjistavropoulos et al 2001).
This focus is also shared in the more recent fear
avoidance models of chronic pain (Asmundson et al
1999, 2004a; Vlaeyen & Linton 2000), wherein pain-
related fear and anxiety are suggested to play primary roles
in the development and maintenance of disabling chronic
pain. The fearavoidance models are predicated on long-
standing observations that fear and anxiety appear to be
critical elements in the pain experience. Indeed, the associ-
ation between fear and pain dates back to at least as early as
Aristotle, who, over 2000 years ago, stated Let fear, then, be
a kind of pain or disturbance resulting the imagination of
impending danger, either destructive or painful, and is an
important consideration in each of the biopsychosocial
models described above. Since fearavoidance models
have stimulated some of the most recent developments
with respect to assessment and case conceptualization for
individuals who have pain lasting beyond the time typical
for physical healing, we provide a more detailed descrip-
tion here.
Contemporary fear-avoidance models of chronic pain
are based primarily on the writings of several scholars
(Asmundson et al 1999; McCracken et al 1992; Vlaeyen
et al 1995; Waddell et al 1993), each of whom provided
slightly different conceptualizations of the role of fear, anx-
iety, and avoidance in perpetuating pain. Subtle differences
aside, the primary postulates of each of these scholars are
captured in the model proposed by Vlaeyen & Linton
Chapter |4|
(2000), and illustrated in Figure 4.1. This model can be
summarized as follows. On perceiving pain, people make
an appraisal of the meaning or purpose of the pain (pain
experience). Most people appraise the pain to be unpleas-
ant and discomforting but not indicative of serious threat
to their well-being (no fear). These people then engage
in appropriate behavioural restriction and graduated
increases in activity (confrontation) until they have healed
(recovery). However, some people appraise the pain as
being indicative of a serious threat to their well-being (pain
catastrophizing) and, influenced by predispositional and
current psychological factors, spiral into a self-perpetuating
cycle characterized by fear (i.e. fear of pain, fear of (re)
injury), activity limitations, disability and pain. It is this
latter group of people who experience pain that lasts
beyond the time expected for normal healing.
This model has served as a useful platform upon which
considerable amounts of empirical research and related
practical applications have been based (for review of find-
ings current to the beginning of this millennium, see
Vlaeyen & Linton 2000; for review of more recent findings,
see Leeuw et al 2007; for review of empirically supported
treatment options, see Bailey et al 2010). In addition to
advances in empirical findings and practical applications
to this field of inquiry, there has been continuing refine-
ment of the contemporary fear-avoidance model (e.g.
Asmundson et al 2004a; Norton & Asmundson 2003).
Summary
The models described above provide comprehensive con-
ceptualizations of pain and chronic pain, with varying
degrees of emphasis on cognitive, behavioural and envi-
ronmental constructs. It is these constructs that form the
basis of conceptually driven assessment and treatment
planning. Below we provide an overview of some of the
most important cognitive, behavioural and environmental
constructs and how these are assessed.
COGNITIVE CONSTRUCTS
Beliefs
Pain beliefs are a broad category of ideations, often cata-
strophic in nature, held by all people, not just those with
chronic pain (van Damme et al 2002; Sullivan et al
2001). An individual forms pain beliefs, which are rela-
tively stable across time, based on past experiences and cul-
tural norms (Turner et al 2004; Werner et al 2005). There
have been several tools designed to measure pain beliefs
(e.g. Edwards et al 1992; Waddell et al 1993; Wallston
et al 1978; Williams & Thorn 1989), any of which can
be used to provide a reliable and valid assessment of the
nature of a persons beliefs about pain.
37
Section | 1 | Overview: what is pain?

Injury

Disuse
Depression Recovery
Disability

Avoidance
hypervigilance

Confrontation
Pain experience

Pain-related
fear

Pain No fear
catastrophizing

Negative affectivity
Threatening illness information

Fig. 4.1 Fear-avoidance model.

Reprinted from Vlaeyan, J.W.S., and Linton, S.J., Fear avoidance and its consequences in chronic musculoskeletal pain: a state of the art. PAIN 2000,
April 85(3); 317-332. This figure has been reproduced with permission of the International Association for the study of Pain (IASP). The figure may
not be reproduced for any other purpose without permision.

Pain beliefs are commonly divided into two subcate-
gories, organic and psychological (Edwards et al 1992).
Organic pain beliefs centre on the notion that pain indi-
cates immediate or imminent physical harm (e.g. Pain is
the result of damage to the tissues of my body). In contrast,
psychological pain beliefs centre on the notion that pain is
mediated by internal and external factors (e.g. Thinking
about pain makes it worse). Pain beliefs have been associ-
ated uniquely and independently with disability and
depression (Turner et al 2000).
There is more than two decades of evidence suggesting
a relationship between organic pain beliefs and physical
disability for patients with chronic pain (Jensen et al
1991; Sloan et al 2007), but the relationship with pain
intensity has been minimal (Edwards et al 1992). In
short, persons who have disabling chronic pain tend to
strongly endorse organic pain beliefs and are less likely
than people without chronic pain to endorse psycholog-
ical pain beliefs (Edwards et al 1992; Walsh & Radcliffe
2002). Because pain beliefs are learned (Turner et al
2004; van Damme et al 2002; Werner et al 2005), they
are also modifiable. Increasing a persons belief that
pain involves a significant psychological component
tends to be associated with decreases in disability and,
often, reports of reduced pain intensity (Bailey et al
2010; de Jong et al 2005; Jensen et al 2001; Walsh &
Radcliffe 2002).
Mood
Depression symptoms have been associated with increased
pain behaviour (e.g. guarding, bracing, rubbing, grimacing,
sighing), reduced individual, social and occupation activ-
ity, as well as increased use of medical services (Arnow
et al 2009; Asmundson et al 2008; Keefe et al 1986;
Ratcliffe et al 2008; Smith et al 1998; Worz 2003). In
chronic pain samples, prevalence rates of clinically signifi-
cant depression vary based on the criteria used for assess-
ment (Geisser et al 1997; Pincus & Williams 1999), but
often exceed 28% (Morley et al 2002; Polatin et al 1993;
Poole et al 2009; Worz 2003); in contrast, lifetime and
12-month community prevalence rates for depression are
approximately 17% and 7%, respectively (Kessler et al
2005a,b). Persons with one pain site are nearly twice as
likely to be depressed than persons with no pain, whereas
persons with more than one pain site are nearly four times
as likely to be depressed (Gureje et al 2008). In addition,
the longer a person is in pain, or the more intense the pain,
the more likely the person is to experience depressive symp-
toms (Krause et al 1994; Odegard et al 2007). Depressive

38
 The psychology of pain: models and targets for comprehensive assessment Chapter |4|

symptoms do not necessarily impede treatment outcomes, painful reinjury (Kori et al 1990), or whether it is best
however, and treating depression itself may provide reduc- subsumed by a fear of somatic sensations and changes
tions in disabling pain symptoms (Glombiewski et al 2010; (Asmundson et al 1999; Greenberg & Burns 2003). Despite
Teh et al 2009). the potential utility of clearly distinguishing between pain-
Assessment of depression symptoms in persons with related anxiety and pain-related fear, additional empirical
chronic pain should be ongoing, as there is evidence that study is required; as such, in the current text, pain-related
pain is associated with fluctuations in mood over time anxiety will be used to refer to both constructs.
(Krause et al 1994; Odegard et al 2007). In addition to The structure of pain-related anxiety appears to be multi-
structured clinical interviews (e.g. First et al 1996), there dimensional (i.e. comprising cognitive, behavioural and
is a variety of standardized self-report tools that can mea- physiological components; McCracken et al 1993) and
sure ongoing depression symptoms (e.g. Beck et al 1988; continuous (i.e. occurring along a continuum ranging from
Radloff 1977). Given the probability of low mood resulting low to high; Asmundson et al 2007). Accordingly, there is
from ongoing pain, the high rates of comorbidity with also evidence that pain-related anxiety is ubiquitous in the
depression, and the associated personal and economic population (Carleton & Asmundson 2007; Carleton et al
costs, ongoing depression symptom assessment should 2009). There have been several tools designed to measure
occur for all patients with disabling chronic pain. pain-related anxiety (e.g. McCracken & Dhingra 2002;
McNeil & Rainwater 1998; Melzack 1983) and ongoing
assessment provides clinicians with information about a
key cognitive component in the maintenance of disabling
Anxiety and fear
chronic pain.
As with depression, persons with one pain site are nearly
twice as likely to have clinically significant levels of anxiety
compared to persons with no pain, whereas persons Spirituality
with more than one pain site are more than three times
Exploration of the relationship between religion, spiritual-
as likely to be anxious (Gureje et al 2008). Findings from
ity and chronic pain remains relatively novel. In a recent
community-dwelling adults in 17 countries (n 85,088)
review, religious and spiritual beliefs were found to repre-
indicate that those with back or neck pain are two to three
sent important components of the chronic pain experience
times more likely to have current (i.e. past 12 months)
(Rippentrop 2005; Unruh 2007). Many people with
panic disorder, agoraphobia or social anxiety disorder,
chronic pain report that religious and spiritual beliefs func-
and almost three times more likely to have generalized
tion as coping mechanisms that facilitate their continued
anxiety disorder (GAD) or post-traumatic stress disorder
activity (Bussing et al 2009), but the available evidence sug-
(PTSD) (Demyttenaere et al 2007). Data on lifetime prev-
gests that religious and spiritual beliefs do not directly
alence show similar patterns. For example, community-
impact pain intensity or pain interference (Rippentrop
dwelling women with fibromyalgia are four to five times
et al 2005). Research to date suggests most people with
more likely to have had a lifetime diagnosis of obses-
chronic pain reporting a religious affiliation neither feel
sivecompulsive disorder, PTSD or GAD than those with-
abandoned nor punished as a function of their religious
out (Raphael et al 2006). In people seeking treatment for
and spiritual beliefs, and that most report prayer to be an
pain, some but not all studies indicate elevated prevalence
important coping strategy (Glover-Graf et al 2007). While
of any current (2529%) and lifetime (28%) anxiety disor-
additional investigation into the impact of religious and
der relative to the general population (18%) (Kessler et al
spiritual beliefs on the pain experience is warranted, there
2005a,b), with specific elevations in the prevalence of cur-
is sufficient evidence to suggest that religious and spiritual
rent seasonal affective disorder, GAD, panic disorder and
beliefs be considered as a component of comprehensive
PTSD (for review, see Asmundson & Katz 2009).
assessment. Several general and well-established measures
Fear and anxiety related to pain are also pertinent issues.
of religious and spiritual beliefs are available (e.g.
The constructs of pain-related anxiety and pain-related fear
Cloninger et al 1994; Piedmont 1999) and more specific
are often used interchangeably, but there is theory and evi-
measures have been developed recently (e.g. Glover-Graf
dence that suggests the two are distinct (Carleton &
et al 2007).
Asmundson 2009). Specifically, pain-related anxiety repre-
sents a response to anticipated future encounters with pain-
related threats that drives avoidance behaviours; in con-
trast, pain-related fear represents a response to a current BEHAVIOURAL CONSTRUCTS
encounter with a pain-related threat that drives escape
behaviours. There are differing opinions about whether
Avoidance behaviour
pain-related fear is focused on painful sensations
(Lethem et al 1983; Vlaeyen & Linton 2000), activities asso- The cognitive constructs described above often serve to
ciated with those sensations (e.g. Waddell et al 1993) or influence the way in which a person with chronic pain

39
Section | 1 | Overview: what is pain?
behaves. Perhaps the most significant pain-related behaviour
is that of avoidance (Asmundson et al 2004b). Indeed, avoid-
ance behaviours are intrinsically appropriate components of
pain (Larsen et al 1997; McCracken et al 1992; Osman et al
1994). Relatively higher levels of pain-related anxiety facili-
tate avoidance that, from the perspective of the person with
chronic pain, provides a protective function (Vlaeyen et al
2004); in short, anticipated pain and additional harm are
skirted. The challenge associated with avoidance is that it does
serve a protective function as part of the recovery process, but
only in the short term. When anxiety drives avoidance
beyond the time required for healing, its once protective func-
tions become maladaptive (Asmundson et al 2004b). Mal-
adaptive avoidance behaviours can be driven by pain-
related beliefs (Waddell et al 1993), anxiety (McCracken &
Dhingra 2002) or fear of re-injury (Kori et al 1990). Avoid-
ance behaviours have been associated with self-reported dis-
ability (Crombez et al 1999; McCracken & Gross 1995;
Osman et al 2001), non-specific physical complaints
(McCracken et al 1998) and reduced physical capacity
(Burns et al 2000). Consequently, assessment of avoidance
behaviour warrants careful attention.
Activity limitation for secondary gain
There is a lack of clarity associated with the terms malinger-
ing and secondary gain (Craig et al 1999; Main 2003),
particularly as clinicians attempt to reconcile both terms
with exaggerations of legitimate symptoms as attempts to
receive help (Rogers & Neumann 2003). Secondary gain
has been defined as acceptable or legitimate interpersonal
advantages that result when one has the symptom of a
physical disease (Fishbain 1994; Fishbain et al 1995). In
contrast, malingering is defined as the false or fraudulent
exaggeration or simulation of physical or mental disease.
Secondary gains are necessary for malingering to occur,
but secondary gains can occur independent of malingering
(Fishbain et al 2004).
Pain behaviours, particularly activity limitations, can
produce positive consequences, such as receiving attention,
decrease of responsibilities or economic compensation, all
of which constitute secondary gains that can aggravate or
maintain pain (Walker et al 2002; Worzer et al 2009). In
addition, litigation (DeBerard et al 2001; Epker & Block
2001; LaCaille et al 2005; Taylor et al 2000) and insurance
or workers compensation (Deyo et al 2005; Epker & Block
2001; Mannion & Elfering 2006; Taylor et al 2000) are
associated with poor surgical outcome (Bruns & Disorbio
2009). Despite the available research, meta-analytic
reviews accounting for severity of pain or disability have
been mixed. Some reviews find more abnormalities and
disability in patients who have financial incentives than
in those without (Binder & Rohling 1996), while other
meta-analytic reviews have found minimal effects of com-
pensation (Rohling et al 1995). Recent longitudinal
40
research suggests that the absence of compensation may
be associated with better post-surgical outcomes (Atlas
et al 2010) and less healthcare utilization (Blyth et al
2003); similarly, patients appear to recover faster post
injury when compensation for pain and suffering is not
available (Cassidy et al 2000). In any case, the historical
evidence suggests that chronic pain is associated with many
more losses than gains (Fishbain 1994).
Pain coping behaviours
Individual beliefs, attitudes and appraisals pertaining to pain
impact pain perception and coping behaviours (Unruh 1996;
Unruh et al 1999). When pain is perceived as challenging or
threatening, pain behaviours often include information seek-
ing, healthcare utilization, seeking social support, problem
solving and increased or decreased use of distraction strate-
gies (for review, see Taylor & Asmundson 2004). Discussion
of the various pain coping behaviours is beyond the scope of
this chapter, but it is important it note that the effectiveness of
these various strategies is often dependent on situational and
individual difference factors. To illustrate, research into the
effectiveness of cognitive control strategies, such as distrac-
tion or suppression of pain-related thoughts, has been equiv-
ocal (for review, see Asmundson et al 2010). Some studies
have supported the use of distraction, particularly for chil-
drens procedural or acute pain, but most indicate that direct-
ing attention away from pain increases pain sensitivity and
pain-related disability. Directing attention towards the sen-
sory quality of pain (i.e. somatic focus) may actually reduce
pain sensitivity, but the effect may depend on the sex of the
person in pain (Keogh et al 2000). The disparate findings also
may relate to psychological individual difference variables,
such that distraction is less effective in persons who catastro-
phize about pain (Goubert et al 2004; Hadjistavropoulos et al
2000; Heyneman et al 1990; Roelofs et al 2004). These indi-
viduals may instead benefit from increasing somatic focus
(Hadjistavropoulos et al 2000; Keogh & Mansoor 2001;
Roelofs et al 2004).
Pain and suicide
Risk of suicide increases when chronic pain becomes over-
whelming. Relative to persons without chronic pain, those
with chronic pain are three times more likely to experience
suicidal ideations and twice as likely to attempt suicide
(Tang & Crane 2006). Up to half of all people with chronic
pain have considered suicide (Hitchcock et al 1994), but
ideation appears more frequent than forming a plan for
or attempting suicide (Smith et al 2004). Chronic pain
appears to play an important role in successful suicides
(Fishbain et al 1991), particularly for older adults, who
are highly susceptible to both psychiatric illness and phys-
ical health conditions (Manthorpe & Illife in press). That
said, the most common method of suicide among people
 The psychology of pain: models and targets for comprehensive assessment
with chronic pain is prescription overdose (Smith et al
2004), which may be associated with increased access to
prescription medications. A more comprehensive discus-
sion of the current state of knowledge regarding suicide
in people with various chronic pain conditions is provided
by El-Gabalawy et al (2011).
ENVIRONMENTAL INFLUENCES
Pain is experienced and acted on within the context of the
environment in which a person operates on a daily basis.
Consequently, pain and pain-related cognitions and
behaviours are influenced by numerous aspects of the envi-
ronment. Here we provide an overview of the influence of
family, culture and ethnicity, socioeconomics, and work
factors on pain.
Family
Family appears to influence pain experiences through both
genetic and social learning mechanisms. An association
between some genes (i.e. the CMT and GTP ciclohydroxi-
lase genes) and pain perception and chronic pain has been
found (Diatchenko et al 2005; Tegeder et al 2006), but
genetic influences are, at minimum, shaped by social learn-
ing. Parents experiencing pain appear to be effective
models of illness behaviours in their children (Osborne
et al 1989). This is illustrated by Goodman & McGrath
(2003), who exposed three groups of children to their
mothers behaviour during a cold pressor task. The mothers
were assigned to three different conditions, including an
exaggerated pain condition (i.e. instructions to exaggerate
pain response), a minimized pain condition (i.e. instructed
to minimize pain response) and a control condition with-
out specific instructions. Children of the mothers
instructed to exaggerate their pain response had lower pain
thresholds and more exaggerated facial responses to cold
pressor than did children of mothers in the control group.
Spouses and significant others (e.g. family members,
friends) can likewise influence the pain and pain behaviour
of the person experiencing pain (for review, see Leonard et al
2006). To illustrate, a spouse may unwittingly contribute to
the persistence of pain by rewarding (e.g. providing atten-
tion or sympathy) pain expression and passively sanctioning
avoidance of unwanted responsibilities or undesirable activ-
ities, by expressing negative emotion toward pain behav-
iours and by responding negatively to well behaviours
(Raichle et al 2011). However, the effects of pain on the fam-
ily need not be negative. Pain might act for some as a stabi-
lizing force and play a substantive role in maintaining family
homeostasis (Turk et al 1992). In the context of assessment
and case conceptualization, it is important that the therapist
be mindful of both negative and positive influences of fam-
ily on the pain experience and pain reports.
Chapter |4|
Culture and ethnicity
Culture can be understood as the knowledge through
which groups of people interpret their lives and direct their
behaviours (Turner 2005). Some aspects of the culture of
an individual can influence how pain is experienced. For
example, those from the Mexican American culture are gen-
erally obligated to bear pain stoically (Villareul 1995). This
expectation may influence both their experience of pain
and the way they communicate pain to others. Culture
can have important influences on the way in which pain
assessment and treatment are conceptualized and prac-
ticed. Mindbody dualism, focus on disease versus illness
and biases toward cure versus care can substantively hinder
successful treatment of pain; as such, some theorists
(Crowley-Matoka et al 2009) have called for general move-
ment towards biopsychosocial models of pain.
Ethnicitycultural groupings traditionally defined by a
common language, religion, nationality or heritage
(Shavers et al 2010) are also related to the way in which
pain is experienced and communicated. Indeed, the preva-
lence of chronic pain has been demonstrated to be signif-
icantly higher for some ethnic groups in North America,
as are adverse outcomes related to pain (for review, see
Anderson et al 2009). For example, Day & Thorn (2010)
found that African Americans report significantly higher
pain intensity and pain interference compared to Cauca-
sian Americans. Others studies suggest that the relationship
between ethnicity and pain is better explained by socioeco-
nomic differences, as the association between ethnicity and
pain outcomes are attenuated when socioeconomic factors
are controlled (Fuentes et al 2007; Stanaway et al 2011).
Craig (Chapter 3) provides a comprehensive discussion
of the influences of culture and ethnicity on pain. In the
context of assessment and case conceptualization, it is
important that the therapist be mindful of potential cul-
tural and ethnic influences on pain experience and pain
reports. It is likewise important that he or she be mindful
of the way in which pain-related information from patients
is received and interpreted; indeed, minorities are rated by
their providers as having less severe pain, less likely to
receive opioid medications and less likely to receive com-
prehensive assessment and treatment when compared
non-Hispanic Caucasian people (Shavers et al 2010).
Socioeconomics
Socioeconomic status (SES) represents a dynamic, multidi-
mensional construct that is a robust determinant of health.
SES has a clear association with pain. Low neighbourhood
SES (i.e. a high percentage of households below the poverty
line, a high percentage of people 25 years old with less
than a high-school education and a high percentage of peo-
ple in the labour force who are unemployed) has been
shown to be associated with increased pain, both sensory
and affective, as well as disability and mood disorders
41
Section | 1 | Overview: what is pain?
in adults with chronic low back pain (Fuentes et al 2007).
Similarly, recent findings indicate that those attending an
emergency room were more likely to self-report chronic ill-
ness and chronic pain if they were homeless, had family
income less than $25 000 and perceived a lack of access
to primary care (Hanley et al 2010). Cano et al (2006) sug-
gest that pain coping strategies may be dependent on cog-
nitive skills that are potentially enhanced by higher
education and primary literacy levels; thus, those with
lower SES may be less likely to cope effectively with pain
and, as a consequence, be more prone to persistence of
their pain experience.
Work
Characteristics of work and the work environment have
emerged as predictors of back pain and disability, even
after controlling for a host of other psychosocial, demo-
graphic and health-related variables (for reviews, see
Crook et al 2002; Hoogendoorn et al 2000; Linton
2001; Shaw et al 2001, 2009). In a recent 2-year longitu-
dinal study performed with neck pain patients, pain was
predicted not only by mechanical factors (e.g. working
with arms raised) but also social factors (e.g. job
demands, decision control, role conflict, empowering
leadership) (Christensen & Knardahl 2010). High work
demands (e.g. long work hours, repetitive work, fatigue),
biomechanical factors (e.g. repetitive and sustained work
posture), and low work support and job satisfaction have
been identified as significant contributing factors to mus-
culoskeletal injury and pain (Crowther & Quayle 2010;
for review, also see Macfarlane et al 2009). The Decade
of the Flag Working Group has recently identified seven
workplace variables that have been shown to contribute
to back pain and pain-related disability: heavy physical
demands, ability to modify work, job stress, social support,
job satisfaction, expectations for resuming work and fear
of re-injury (Shaw et al 2009). Consequently, compre-
hensive assessment of pain may necessitate consideration
of physical, psychological and social factors of work and
the work place.
KEY CONSIDERATIONS IN
ASSESSMENT AND CASE
CONCEPTUALIZATION
Assessment and case
conceptualization
Careful and comprehensive assessment of pain is a neces-
sary component of any treatment plan and any empirical
pursuit wherein pain is of interest, and is covered in detail
in Chapter 7. It is beyond the scope of this chapter to review
the potential complexities associated with a comprehensive
42
assessment of pain. Instead, we provide some general
guidelines to facilitate a comprehensive and multidimen-
sional assessment approach (see also Dworkin et al 2005;
Tait 1999), all predicated on the notion that assessment
is a conceptually driven process. First, we recommend that
assessment include consideration of pain severity or inten-
sity, pain location and distribution, as well as pain stability
(e.g. intermittent vs persistent) and durations. Second, we
recommend that some measure of physical functioning be
included in assessment. The experience of chronic pain is
not homogenous and, as such, some people with chronic
pain function well whereas others do not. The extent of
functional limitation, which may or may not be associated
with pain severity or intensity (Turk 2002), is important for
directing treatment. Third, we recommend consideration of
the various empirically supported and theoretically rele-
vant cognitive, behavioural and environment influences
described above. Person-specific circumstances can aid in
tailoring selection of constructs for assessment, for example
ones living circumstances, religious beliefs and current
work status may dictate whether measures related to these
areas are used. Consideration of convenience and time
commitments for the patient and assessor are also impor-
tant in selecting constructs that will be assessed. Is there
expertise to assess comorbid psychopathology? Is there
time to do so? If so, there are several structured clinical
interviews that a trained clinician can use for this purpose.
If not, there are a variety of self-report and clinician-
administered measures that can be used to screen for signif-
icant symptoms of psychopathology which, in turn, can be
more thoroughly evaluated as necessary. Finally, we recom-
mend selection of a core set of measures that can be used to
gauge progress over time. This core set of measures should
tap the pain experience, physical functioning and psycho-
social factors associated with pain.
Treatment overview
Across the available treatment alternatives, the overwhelm-
ing evidence for more than two decades suggests that multi-
disciplinary treatments (i.e. those involving biological
and psychosocial interventions) result in better treatment
outcomes than unimodal treatments (i.e. biological inter-
ventions or physical therapy) for patients with chronic
pain (for review, see Flor et al 1992). Reviews of multidis-
ciplinary treatment programmes suggest that they are
not only therapeutically effective, but also cost-effective
(for review, see Gatchel & Okifuji 2006). Irrespective of
specific underlying causes, there is growing evidence that
pain-related anxiety and fear can both be reduced using
exposure-based therapies that encourage confronting
anxiety- and fear-related stimuli (Asmundson et al
2004b; Bailey et al 2010; McCracken 1997; McCracken
et al 1992). For discussion about psychological interven-
tions see Chapters 8 and 9 in this text.
 The psychology of pain: models and targets for comprehensive assessment
CONCLUSION
Contemporary biopsychosocial approaches to under-
standing pain provide a sound foundation on which
comprehensive assessment, case conceptualization and
REFERENCES
Anderson, K.O., Green, C.R., Payne, R.,
2009. Racial and ethnic disparities in
pain: Causes and consequences of
unequal care. J. Pain. 10, 11871204.
Arnow, B.A., Blasey, C.M., Lee, J., et al.,
2009. Relationships among
depression, chronic pain, chronic
disabling pain, and medical costs.
Psychiatr. Serv. 60, 344350.
Asmundson, G.J.G.,
Hadjistavropoulos, H.D., 2006.
Addressing shared vulnerability
for PTSD and chronic pain: A
cognitive-behavioral perspective.
Cognitive and Behavioral Practice
13, 816.
Asmundson, G.J.G., Katz, J., 2009.
Understanding the co-occurrence
of anxiety disorders and chronic
musculoskeletal pain: The state-
of-the-art. Depress. Anxiety
26, 888901.
Asmundson, G.J.G., Wright, K.D., 2004.
Biopsychosocial approaches to pain.
In: Hadjistavropoulos, T., Craig, K.D.
(Eds.), Pain: Psychological
Perspectives. Erlbaum, New Jersey,
pp. 3557.
Asmundson, G.J.G., Norton, G.R.,
Allerdings, M.D., et al., 1998.
Posttraumatic stress disorder and
work-related injury. J. Anxiety Disord.
12, 5769.
Asmundson, G.J.G., Norton, P.J.,
Norton, G.R., 1999. Beyond pain: The
role of fear and avoidance in
chronicity. Clin. Psychol. Rev. 19,
97119.
Asmundson, G.J.G., Norton, P.J.,
Vlaeyen, J.W.S., 2004a. Fear-
avoidance models of chronic pain: An
overview. In: Asmundson, G.J.G.,
Vlaeyen, J.W.S., Crombez, G. (Eds.),
Understanding and Treating Fear of
Pain. Oxford University Press, Oxford,
pp. 324.
Asmundson, G.J.G., Vlaeyen, J.W.S.,
Crombez, G., 2004b. Understanding
treatment planning can be based. While each case may
involve consideration of different biological, psycho-
logical and social factors in the context of the pain expe-
rience, it is careful consideration of these factors that
will ultimately lead to the best outcomes for those dis-
abled by pain.
and treating fear of pain. Oxford
University Press, Oxford.
Asmundson, G.J.G., Collimore, K.C.,
Bernstein, A., et al., 2007. Is the latent
structure of fear of pain continuous or
discontinuous among pain patients?
Taxometric analysis of the pain
anxiety symptoms scale. J. Pain 8,
387395.
Asmundson, G.J.G., Abrams, M.P.,
Collimore, K.C., 2008. Pain and
anxiety disorders. In: Zvolensky, M.J.,
Smits, J.A.J. (Eds.), Health behaviors
and physical illness in anxiety and its
disorders: Contemporary theory and
research. Springer, New York,
pp. 207235.
Asmundson, G.J.G., Peluso, D.,
Carleton, R.N., et al., 2010.
Chronic Musculoskeletal Pain
and Related Health Conditions. In:
Zvolensky, M.J., Bernstein, A.,
Vujanovic, A.A. (Eds.),
Distress Tolerance: Theory,
Research, and Clinical Applications.
Guilford Publications, New York,
pp. 221244.
Atlas, S.J., Tosteson, T.D., Blood, E.A.,
et al., 2010. The impact of
workers compensation on
outcomes of surgical and
nonoperative therapy for
patients with a lumbar disc herniation
SPORT. Spine 35, 8997.
Bailey, K.M., Carleton, R.N.,
Vlaeyen, J.W.S., et al., 2010.
Treatments addressing pain-related
fear and anxiety in patients with
chronic musculoskeletal pain: A
preliminary review. Cogn. Behav.
Ther. 39, 4663.
Beck, A.T., Epstein, N., Brown, G., et al.,
1988. An inventory for measuring
clinical anxiety: Psychometric
properties. J. Consult. Clin. Psychol.
56, 893897.
Binder, L.M., Rohling, M.L., 1996. Money
matters: A meta-analytic review of the
Chapter |4|
effects of financial incentives on
recovery after closed-head injury. Am.
J. Psychiatry 153, 710.
Blyth, F.M., March, L.M., Nicholas, M.K.,
et al., 2003. Chronic pain, work
performance and litigation.
Pain 103, 4147.
Bruns, D., Disorbio, J.M., 2009.
Assessment of biopsychosocial risk
factors for medical treatment: a
collaborative approach. J. Clin.
Psychol. Med. Settings 16, 127147.
Burns, J.W., Mullen, J.T., Higdon, L.J.,
et al., 2000. Validity of the Pain
Anxiety Symptoms Scale (PASS):
Prediction of physical capacity
variables. Pain 84, 247252.
Bussing, A., Michalsen, A., Balzat, H.,
et al., 2009. Are spirituality and
religiosity resources for patients with
chronic pain conditions? Pain Med.
10, 327339.
Cano, A., Mayo, A., Ventimiglia, M.,
2006. Coping, pain severity,
interference, and disability: the
potential mediating and moderating
roles of race and education. J. Pain 7,
459468.
Carleton, R.N., Asmundson, G.J.G., 2007.
Review of cognitive-behavioral
therapies for trauma, 2nd edn.
Canadian Psychology/Psychologie
Canadienne 48, 201203.
Carleton, R.N., Asmundson, G.J.G., 2009.
The multidimensionality of fear of
pain: Construct independence for the
Fear of Pain Questionnaire-Short
Form and the Pain Anxiety Symptoms
Scale-20. J. Pain 10, 2937.
Carleton, R.N., Abrams, M.P.,
Asmundson, G.J.G., et al., 2009.
Pain-related anxiety and anxiety
sensitivity across anxiety and
depressive disorders. J. Anxiety
Disord. 23, 791798.
Cassidy, J.D., Carroll, L.J., Cote, P., et al.,
2000. Effect of eliminating
compensation for pain and suffering
43
Section | 1 | Overview: what is pain?
on the outcome of insurance claims
for whiplash injury. N. Engl. J. Med.
342, 11791186.
Christensen, J.O., Knardahl, S., 2010.
Work and neck pain: A prospective
study of psychological, social, and
mechanical risk factors. Pain 151,
162173.
Cloninger, R.C., Przybeck, T.R.,
Svrakic, D.M., et al., 1994. The
Temperament and Character
Inventory (TCI): A guide to its
development and use. Center for
Psychobiology of Personality,
Washington University, St Louis, MO.
Craig, K.D., Hill, M.L., McMurty, B.W.,
1999. Detecting deception and
malingering. In: Block, A.R.,
Kramer, E.F., Fernandez, E. (Eds.),
Handbook of pain syndromes:
biopsychosocial perspectives.
Lawrence Erlbaum, Mahwah, New
Jersey, pp. 4158.
Crombez, G., Vlaeyen, J.W.S.,
Heuts, P.H.T.G., et al., 1999.
Pain-related fear is more disabling
than pain itself: Evidence on the
role of pain-related fear in chronic
back pain disability. Pain 80,
329339.
Crook, J., Milner, R., Schultz, I.Z., et al.,
2002. Determinants of occupational
disability following a back
injury: A critical review of the
literature. J. Occup. Rehabil. 12,
277295.
Crowley-Matoka, M., Saha, S.,
Dobscha, S.K., et al., 2009.
Problems of quality and equity in
pain management: exploring the
role of biomedical culture. Pain Med.
10, 13121324.
Crowther, I.E., Quayle, L., 2010.
Womens health at work program.
Musculoskeletal pain experience by
women of Chinese background
working on market gardens in the
Sydney basin. Work 36, 129140.
Day, M.A., Thorn, B.E., 2010. The
relationship of demographic and
psychosocial variables to pain-related
outcomes in a rural chronic pain
population. Pain. http://dx.doi.org/
10.1016/j.pain.2010.08.015.
DeBerard, M.S., Masters, K.S.,
Colledge, A.L., et al., 2001. Outcomes
of posterolateral lumbar fusion in
Utah patients receiving workers
compensation: A retrospective cohort
study. Spine 26, 738746.
44
de Jong, J.R., Vlaeyen, J.W., Onghena, P.,
et al., 2005. Fear of movement/(re)
injury in chronic low back pain:
education or exposure in vivo as
mediator to fear reduction? Clin. J.
Pain 21, 917.
Demyttenaere, K., Bruffaerts, R., Lee, S.,
et al., 2007. Mental disorders among
persons with chronic back or neck
pain: results from the World Mental
Health Surveys. Pain 129, 332342.
Deyo, R.A., Mirza, S.K., Heagerty, P.J.,
et al., 2005. A prospective cohort study
of surgical treatment for back pain
with degenerated discs; study
protocol. BMC Musculoskelet.
Disord. 6, 24.
Diatchenko, L., Slade, G.D.,
Nackley, A.G., et al., 2005. Genetic
basis for individual variations in pain
perception and the development of a
chronic pain condition. Hum. Mol.
Genet. 14, 135143.
Dworkin, R.H., Turk, D.C., Farrar, J.T.,
et al., 2005. Core outcome measures
for chronic pain clinical trials:
IMMPACT recommendations. Pain
113, 919.
Edwards, L.C., Pearce, S.A.,
Turner-Stokes, L., et al., 1992. The
Pain Beliefs Questionnaire: an
investigation of beliefs in the causes
and consequences of pain. Pain 51,
267272.
El-Gabalawy, R., Asmundson, G.J.G.,
Sareen, J., 2011. Suicide and chronic
pain. In: Pompili, M., Berman, L.
(Eds.), Suicide Risk and Physical
Illness. American Association of
Suicidology, Washington, DC,
pp. 7586.
Epker, J., Block, A.R., 2001. Presurgical
psychological screening in back pain
patients: A review. Clin. J. Pain 17,
200205.
First, M., Spitzer, R., Gibbon, M., et al.,
1996. Structured Clinical Interview for
DSM-IV Axis I Disorders Patient
edition. New York State Psychiatric
Institute, Biometrics Research
Department, New York.
Fishbain, D.A., 1994. Secondary gain
concept: Definition problems and its
abuse in medical practice. APS Journal
3, 264273.
Fishbain, D.A., Goldberg, M.,
Rosomoff, R.S., et al., 1991.
Case Reports: Completed Suicide
in Chronic Pain. Clin. J. Pain 7,
2936.
Fishbain, D.A., Rosomoff, H.L., Cutler, R.,
et al., 1995. Do chronic pain patients
perceptions about their preinjury jobs
determine their intent to return to the
same type of job post-pain facility
treatment? Clin. J. Pain. 11, 267278.
Fishbain, D.A., Cutler, R.B., Lewis, J.,
et al., 2004. Do the Second-
Generation Atypical Neuroleptics
have analgesic properties? A
structured evidenced-based review.
Pain Med. 5, 359365.
Flor, H., Fydrich, T., Turk, D.C., 1992.
Efficacy of multidisciplinary pain
treatment centers: a meta-analytic
review. Pain 49, 221230.
Fordyce, W.E., 1976. Behavioral methods
for chronic pain and illness. Mosby, St
Louis, MO.
Fordyce, W.E., Shelton, J.L.,
Dundore, D.E., 1982. The
modification of avoidance learning
pain behaviors. J. Behav. Med. 5,
405414.
Fuentes, M., Hart-Johnson, T.,
Green, C.R., 2007. The Association
among Neighborhood
Socioeconomic Status, Race and
Chronic Pain in Black and White
Older Adults. J. Natl. Med. Assoc. 99,
11601169.
Gatchel, R.J., Okifuji, A., 2006. Evidence-
based scientific data documenting the
treatment and cost-effectiveness of
comprehensive pain programs for
chronic nonmalignant pain. J. Pain 7
(11), 779793.
Geisser, M.E., Roth, R.S., Robinson, M.E.,
1997. Assessing depression among
persons with chronic pain using the
Center for Epidemiological Studies
Depression Scale and the Beck
Depression Inventory: a comparative
analysis. Clin. J. Pain 13, 163170.
Glombiewski, J.A., Hartwich-Tersek, J.,
Rief, W., 2010. Depression in chronic
back pain patients: Prediction of
pain intensity and pain disability
in cognitive-behavioral
treatment. Psychosomatics 51,
130136.
Glover-Graf, N.M., Marini, I., Baker, J.,
et al., 2007. Religious and spiritual
beliefs and practices of persons with
chronic pain. Rehabilitation
Counseling Bulletin 51, 2133.
Goodman, J.E., McGrath, P.J., 2003.
Mothers modeling influences
childrens pain during a cold presor
task. Pain 104, 559565.
 The psychology of pain: models and targets for comprehensive assessment
Goubert, L., Crombez, G.,
Van Damme, S., 2004. The role of
neuroticism, pain catastrophizing and
pain-related fear in vigilance to pain: a
structural equations approach. Pain
107, 234241.
Greenberg, J., Burns, J.W., 2003. Pain
anxiety among chronic pain patients:
specific phobia or manifestation of
anxiety sensitivity? Behav. Res. Ther.
41, 223240.
Gureje, O., Von Korff, M., Kola, L., et al.,
2008. The relation between multiple
pains and mental disorders: Results
from the World Mental Health
Surveys. Pain 135, 8291.
Hadjistavropoulos, H.D.,
Hadjistavropoulos, T., Quine, A.,
2000. Health anxiety moderates the
effects of distraction versus attention
to pain. Behav. Res. Ther. 38,
425438.
Hadjistavropoulos, H.D., Owens, K.M.B.,
Hadjistavropoulos, T., et al., 2001.
Hypochondriasis and health anxiety
among pain patients. In:
Asmundson, G.J.G., Taylor, S.,
Cox, B.J. (Eds.), Health Anxiety:
Clinical and research perspectives on
hypochondriasis and related
conditions. John Wiley & Sons,
Toronto, pp. 298323.
Hanley, O., Miner, J., Rockswold, E.,
et al., 2010. The relationship
between chronic illness, chronic
pain, and socioeconomic factors
in the ED. Am. J. Emerg. Med.
http://dx.doi.org/10.1016/j.
ajem.2009.10.002.
Heyneman, N.E., Fremouw, W.J.,
Gano, D., et al., 1990. Individual
differences and the effectiveness
of different coping strategies
for pain. Cogn. Behav. Ther. 14,
6377.
Hitchcock, L.S., Ferrell, B.R.,
McCaffery, M., 1994. The
experience of chronic nonmalignant
pain. J. Pain Symptom. Manage. 9,
312318.
Hoogendoorn, W.E., van Poppel, M.N.,
Bongers, P.M., et al., 2000.
Systematic review of psychosocial
factors at work and private life as
risk factors for back pain. Spine. 25,
21142125.
International Association for the Study
of Pain, 1986. Classification of
chronic pain: Descriptions of
chronic pain syndromes and
definitions of pain terms. Pain.
(Suppl. 3), 1222.
Jensen, M.P., Turner, J.A., Romano, J.M.,
et al., 1991. Coping with chronic pain:
A critical review of the literature. Pain.
47, 249283.
Jensen, M.P., Turner, J.A., Romano, J.M.,
2001. Changes in beliefs,
catastrophizing, and coping are
associated with improvement in
multidisciplinary pain treatment.
J. Consult. Clin. Psychol. 69,
655662.
Keefe, F.J., Wilkins, R.H., Cook Jr., W.A.,
et al., 1986. Depression, pain, and
pain behavior. J. Consult. Clin.
Psychol. 54, 665669.
Keogh, E., Mansoor, L., 2001.
Investigating the effects of anxiety
sensitivity and coping on the
perception of cold pressor pain in
healthy women. Eur. J. Pain 5,
1122.
Keogh, E., Hatton, H., Ellery, D., 2000.
Avoidance versus focused attention
and the perception of pain:
differential effects for men and
women. Pain 85, 225230.
Kessler, R.C., Berglund, P., Demler, O.,
et al., 2005a. Lifetime prevalence
and age-of-onset distributions
of DSM-IV disorders in the
National Comorbidity Survey
Replication. Arch. Gen. Psychiatry 62,
593602.
Kessler, R.C., Chiu, W.T., Demler, O.,
et al., 2005b. Prevalence, severity, and
comorbidity of 12-month DSM-IV
disorders in the National
Comorbidity Survey Replication.
Arch. Gen. Psychiatry 62, 617627.
Kori, S.H., Miller, R.P., Todd, D.D., 1990.
Kinesiophobia: A new view of chronic
pain behavior. Pain Management 3,
3543.
Krause, S.J., Weiner, R.L., Tait, R.C., 1994.
Depression and pain behavior in
patients with chronic pain. Clin. J.
Pain 10, 122127.
LaCaille, R.A., DeBerard, M.S.,
Masters, K.S., et al., 2005.
Presurgical biopsychosocial
factors predict multidimensional
patient outcomes of interbody
cage lumbar fusion. Spine J. 5 (1),
7178.
Larsen, D.K., Taylor, S.,
Asmundson, G.J.G., 1997.
Exploratory factor analysis of the Pain
Anxiety Symptoms Scale in patients
Chapter |4|
with chronic pain complaints. Pain
69, 2734.
Leeuw, M., Peters, M.L., Wiers, R.W.,
et al., 2007. Measuring fear
of movement/(re)injury in chronic
low back pain using implicit
measures. Cogn. Behav. Ther. 36,
5264.
Leonard, M.T., Cano, A., Johansen, A.B.,
2006. Chronic pain in a couples
context: a review and integration of
theoretical models and empirical
evidence. J. Pain 7, 377390.
Lethem, J., Slade, P.D., Troup, J.D., et al.,
1983. Outline of a fear-
avoidance model of exaggerated
pain perception: I. Behav. Res. Ther.
21, 401408.
Linton, S.J., 2001. Occupational
psychological factors increase the
risk for back pain: a systematic review.
J. Occup. Rehabil. 11, 5366.
Main, C.J., 2003. The nature of chronic
pain: a clinical and legal challenge. In:
Hallingan, P.W., Bass, C., Oakley, D.A.
(Eds.), Malingering and Illness
Deception. Oxford University Press,
New York, pp. 171183.
Macfarlane, G.J., Pallewatte, N.,
Paudyal, P., et al., 2009. Evaluation of
work-related psychosocial factors and
regional musculoskeletal pain: results
from a EULAR Task Force. Annual of
Rheumatic Diseases 68, 885891.
Mannion, A.F., Elfering, A., 2006.
Predictors of surgical outcome and
their assessment. Eur. Spine J. 15,
S93S108.
Manthorpe, J., Illife, S., in press Suicide in
later life: public health and
practitioner perspectives. Int. J.
Geriatr. Psychiatry 25, 12301238.
McCracken, L.M., 1997. Attention to
pain in persons with chronic pain: a
behavioral approach. Behaviour
Therapy 28, 271284.
McCracken, L.M., Dhingra, L., 2002. A
short version of the pain anxiety
symptoms scale (PASS-20):
Preliminary development and
validity. Pain Res. Manag. 7, 4550.
McCracken, L.M., Gross, R.T., 1995. The
pain anxiety symptoms scale
(PASS) and the assessment of
emotional responses to pain. In:
VandeCreek, L., Knapp, S.,
Jackson, T.L. (Eds.), Innovations in
clinical practice: a sourcebook.
Professional Resources Press,
Sarasota, FL, pp. 309321.
45
Section | 1 | Overview: what is pain?
McCracken, L.M., Zayfert, C., Gross, R.T.,
1992. The pain anxiety symptoms
scale: Development and validation of
a scale to measure fear of pain.
Pain 50, 6773.
McCracken, L.M., Zayfert, C., Gross, R.T.,
1993. The pain anxiety symptoms
scale (PASS): a multimodal measure
of pain-specific anxiety symptoms.
Behavior Therapist 16, 183184.
McCracken, L.M., Faber, S.D.,
Janeck, A.S., 1998. Pain-related
anxiety predicts nonspecific
physical complaints in persons with
chronic pain. Behav. Res. Ther. 36,
621630.
McNeil, D.W., Rainwater, A.J., 1998.
Development of the fear of pain
questionnaire-III. J. Behav. Med. 21,
389410.
McWilliams, L.A., Cox, B.J., Enns, M.W.,
2003. Mood and anxiety disorders
associated with chronic pain: an
examination in a nationally
representative sample. Pain 106,
127133.
Mechanic, D., 1962. The concept of
illness behavior. J. Chronic Dis.
15, 189194.
Melzack, R., 1983. The McGill Pain
Questionnaire. In: Melzack, R. (Ed.),
Pain Measurement and Assessment.
Raven Press, New York, pp. 4147.
Melzack, R., 1999. From the gate to the
neuromatrix. Pain (Suppl. 6),
S121S126.
Merskey, H., Bogduk, N., 1994.
Classification of chronic pain:
descriptions of chronic pain
syndromes and definitions of pain
terms, second ed. IASP Press, Seattle.
Melzack, R., Casey, K.L., 1968. Sensory,
motivational and central control
determinants of pain. In:
Kenshalo, D.R. (Ed.), The Skin Senses.
CC Thomas, Springfield, IL,
pp. 423439.
Melzack, R., Katz, J., 2004. The gate
control theory: Reaching for the Brain.
In: Craig, K.D., Hadjistavropoulos, T.
(Eds.), Pain: Psychological
Perspectives. Lawrence Erlbaum,
Mahwah, NJ, pp. 303322.
Melzack, R., Wall, P.D., 1965. Pain
mechanisms: a new theory. Science
150, 971979.
Morley, S., Williams, A.C., Black, S., 2002.
A confirmatory factor analysis of the
Beck Depression Inventory in chronic
pain. Pain 99, 289298.
46
Norton, P.J., Asmundson, G.J.G., 2003.
Amending the fear-avoidance model
of chronic pain: What is the role of
physiological arousal? Behav. Ther.
34, 1730.
Odegard, S., Finset, A., Mowinckel, P.,
et al., 2007. Pain and psychology
health status over a 10 year period in
patients with recent onset rheumatoid
arthritis. Ann. Rheum. Dis. 66,
11951201.
Osborne, R.B., Hatcher, J.W.,
Richtsmeier, A.J., 1989. The role of
social modeling in unexplained
pediatric pain. J. Pediatr. Psychol. 14,
4361.
Osman, A., Barrios, F.X., Osman, J.R.,
et al., 1994. The Pain
Anxiety Symptoms Scale:
psychometric properties in a
community sample. J. Behav. Med. 17
(5), 511522.
Osman, A., Breitenstein, J.L., Barrios, F.X.,
et al., 2001. The fear of pain
questionnaire-III: further reliability
and validity with nonclinical samples.
J. Behav. Med. 25, 155173.
Parsons, T., 1951. The Social System. Free
Press, New York.
Piedmont, R.L., 1999. Does spirituality
represent the sixth factor of
personality? Spiritual transcendence
and the five-factor model. J. Pers. 67,
9851013.
Pincus, T., Williams, A., 1999. Models
and measurements of depression in
chronic pain. J. Psychosom. Res. 47,
211219.
Polatin, P.B., Kinney, R.K., Gatchel, R.J.,
et al., 1993. Psychiatric illness and
chronic low-back pain. The mind and
the spine which goes first? Spine 18,
6671.
Poole, H., White, S., Blake, C., et al., 2009.
Depression in Chronic Pain Patients:
Prevalence and Measurement. Pain
Pract. 9, 173180.
Price, D.D., 2000. Psychological and
neural mechanisms of the affective
dimension of pain. Science. 288,
17691772.
Radloff, L.S., 1977. The CES-D Scale:
A self-report depression scale for
research in the general population.
Applied Psychological Measurement.
1, 385401.
Raichle, K.A., Romano, J.M., Jensen, M.P.,
2011. Partner responses to patient
pain and well behaviors and their
relationship to patient pain behavior,
functioning, and depression. Pain
152, 8288.
Raphael, K.G., Janal, M.N., Nayak, S.,
et al., 2006. Psychiatric comorbidities
in a community sample of women
with fibromyalgia. Pain 124,
117125.
Ratcliffe, G.E., Enns, M.W., Belik, S.L.,
et al., 2008. Chronic pain conditions
and suicidal ideation and suicide
attempts: An epidemiologic
perspective. Clin. J. Pain 24,
204210.
Rippentrop, E.A., 2005. A review of the
role of religion and spirituality in
chronic pain populations.
Rehabilitation Psychology 50,
278284.
Rippentrop, E.A., Altmaier, E.M., Chen, J.,
et al., 2005. The relationship between
religion/spirituality and physical
health, mental health, and pain in a
chronic pain population. Pain 116,
311321.
Roelofs, J., Peters, M.L.,
van der Zijden, M., et al., 2004. Does
fear of pain moderate the effects of
sensory focusing and distraction on
cold pressor pain in pain-free
individuals? J. Pain 5, 250256.
Rogers, R., Neumann, C.S., 2003.
Conceptual issues and explanatory
models of malingering. In:
Halligan, P.W., Bass, C., Oakley, D.A.
(Eds.), Malingering and illness
deception: Clinical and theoretical
perspectives. Oxford University Press,
Oxford, pp. 7182.
Rohling, M.L., Binder, L.M.,
Langhirinrichsen-Rohling, J., 1995.
Money matters: a meta-analytic review
of the association between financial
compensation and the experience and
treatment of chronic pain. Health
Psychol. 14, 537547.
Shavers, V.L., Bakos, A., Sheppard, V.B.,
2010. Race, Ethnicity, and Pain
among the US Adult Population. J.
Health Care Poor Underserved 21,
177220.
Shaw, W.S., Pransky, G., Fitzgerald, T.E.,
2001. Early prognosis for low back
disability: intervention strategies for
health care providers. Disabil.
Rehabil. 23, 815828.
Shaw, W.S., van der Windt, D.A.,
Main, C.J., et al., the Decade of the
Flags Working Group, 2009. Early
Patient Screening and Intervention to
Address Individual-Level
 The psychology of pain: models and targets for comprehensive assessment
Occupational Factors (Blue Flags) in
Back Disability. J. Occup. Rehabil. 19,
6480.
Sloan, T.J., Gupta, R., Zhang, W., et al.,
2007. Beliefs about the causes and
consequences of pain in patients with
chronic inflammatory or
noninflammatory low back pain and
in pain-free individuals. Spine 33,
966972.
Smith, W.B., Gracely, R.H., Safer, M.A.,
1998. The meaning of pain: Cancer
patients rating and recall of pain
intensity and affect. Pain 78,
123129.
Smith, M.T., Edwards, R.R.,
Robinson, R.C., et al., 2004. Suicidal
ideation, plans, and attempts in
chronic pain patients: factors
associated with increased risk. Pain
111, 201208.
Spengler, D.M., Bigos, S.J., Martin, N.A.,
1986. Back injuries in industry: A
retrospective study. 1. Overview and
cost analysis. Spine 11, 241245.
Stanaway, F.F., Blyth, F.M.,
Cumming, R.G., et al., 2011. Back
pain in older male Italian-born
immigrants in. The importance of
socioeconomic factors. Eur. J. Pain,
Australia http://dx.doi.org/10.1016/j.
ejpain.2010.05.009.
Stewart, W.F., Ricci, J.A., Chee, E., et al.,
2003. Lost productive time and cost
due to common pain conditions in
the US workforce. J. Am. Med. Assoc.
290, 24432454.
Sullivan, M.J.L., Thorn, B.,
Haythornthwaite, J.A., et al., 2001.
Theoretical perspectives on the
relation between catastrophizing and
pain. Clin. J. Pain 17, 5264.
Tait, R., 1999. Evaluation of treatment
effectiveness in patients with
intractable pain: Measures and
methods. In: Gatchel, R.J., Turk, D.C.
(Eds.), Psychosocial factors in pain:
Critical perspectives. Guilford Press,
New York, pp. 457480.
Tang, N.K.Y., Crane, C., 2006. Suicidality
in chronic pain: a review of the
prevalence, risk factors and
psychological links. Psychol. Med. 36,
575586.
Taylor, S., Asmundson, G.J.G., 2004.
Treating health anxiety: A cognitive-
behavioral approach. Guilford Press,
New York.
Taylor, V.M., Deyo, R.A., Ciol, M., et al.,
2000. Patient-oriented outcomes from
low back surgery: A community-based
study. Spine 25, 24452452.
Tegeder, I., Costigan, M., Griffin, R.S.,
et al., 2006. GTP cyclohydrolase and
tetrahydrobiopterin regulate pain
sensitivity and persistence. Nat. Med.
12, 12691277.
Teh, C.F., Zaslavsky, A.M., Reynolds, C.F.,
et al., 2009. Effect of depression
treatment on chronic pain outcomes.
Psychosom. Med. 72, 6167.
Turk, D.C., 2002. A diathesis-stress model
of chronic pain and disability
following traumatic injury. Pain Res.
Manag. 7, 919.
Turk, D.C., Flor, H., 1999. The
biobehavioral perspective of pain. In:
Gatchel, R.J., Turk, D.C. (Eds.),
Psychosocial factors in pain. Clinical
perspectives. Guilford Press, New
York, pp. 1834.
Turk, D.C., Rudy, T.E., 1987. IASP
taxonomy of chronic pain syndromes:
Preliminary assessment of reliability.
Pain 30, 177189.
Turk, D.C., Meichenbaum, D.,
Genest, M., 1983. Pain and behavioral
medicine: A cognitive-behavioral
perspective. Guilford Press,
New York.
Turk, D.C., Kerns, R.D., Rosenberg, R.,
1992. Effects of marital interaction on
chronic pain and disability:
Examining the down side of social
support. Rehabilitation Psychology
37, 259274.
Turner, L., 2005. From the local to the
global: bioethics and the concept of
culture. J. Med. Philos. 30, 305320.
Turner, J.A., Jensen, M.P., Romano, J.M.,
2000. Do beliefs, coping, and
catastrophizing independently predict
functioning in patients with chronic
pain? Pain 85, 115125.
Turner, J.A., Mancl, L., Aaron, L.A., 2004.
Pain-related catastrophizing: a daily
process study. Pain 110, 103111.
Unruh, A.M., 1996. Gender variations in
clinical pain experience. Pain 65,
123167.
Unruh, A.M., 2007. Spirituality, religion
and pain. Can. J. Nurs. Res. 39, 6686.
Unruh, A.M., Ritchie, J.A., Merskey, H.,
1999. Does gender affect appraisal of
pain and pain coping strategies? Clin.
J. Pain 15, 3140.
Van Damme, S., Crombez, G.,
Bijttebier, P., et al., 2002. A
confirmatory factor analysis of the
pain catastrophizing scale: invariant
Chapter |4|
factor structure across clinical and
non-clinical populations. Pain 96,
319324.
Villareul, A.M., 1995. Mexican-American
cultural meanings, expressions,
self-care and dependent-care
actions associated with experiences
of pain. Res. Nurs. Health 18,
427436.
Vlaeyen, J.W.S., Linton, S.J., 2000.
Fear-avoidance and its consequences
in chronic musculoskeletal
pain: A state of the art. Pain 85,
317332.
Vlaeyen, J.W.S., Kole-Snijders, A.M.,
Boeren, R.G., et al., 1995. Fear of
movement/(re)injury in chronic low
back pain and its relation to
behavioral performance. Pain 62,
363372.
Vlaeyen, J.W.S., de Jong, J., Leeuw, M.,
et al., 2004. Fear reduction in chronic
pain: graded exposure in vivo with
behavioral experiments. In:
Asmundson, G.J., Vlaeyen, J.W.S.,
Crombez, G. (Eds.), Understanding
and treating fear of pain. Oxford
University Press, Oxford.
Waddell, G., 1987. A new clinical model
for the treatment of low back pain.
Spine 12, 623644.
Waddell, G., Main, C.J., Morris, E.W.,
et al., 1984. Chronic low-back pain,
psychologic distress, and
illness behavior. Spine 9 (2),
209213.
Waddell, G., Newton, M., Henderson, I.,
et al., 1993. A Fear-Avoidance Beliefs
Questionnaire (FABQ) and the role of
fear-avoidance beliefs in chronic low
back pain and disability. Pain 52,
157168.
Walker, L.S., Claar, R.L., Garber, J., 2002.
Social consequences of childrens
pain: When do they encourage
symptom maintenance? J. Pediatr.
Psychol. 27, 689698.
Wall, P.D., 1996. Comments after 30
years of the gate control theory of
pain. Pain Forum 5, 1222.
Wallston, K.A., Wallston, B.S.,
DeVellis, R., 1978. Development of
the multidimensional health locus of
control (MHLC) scale. Health Educ.
Monogr. 6, 525.
Walsh, D.A., Radcliffe, J.C., 2002.
Pain beliefs and perceived
physical disability of patients with
chronic low back pain. Pain 97,
2331.
47
Section | 1 | Overview: what is pain?

Werner, E.L., Ihlebaek, C., Skouen, J.S.,
et al., 2005. Beliefs about low
back pain in the Norwegian general
population: are they related to
pain experiences and health
professionals? Spine. 30,
17701776.
Williams, D.A., Thorn, B.E., 1989. An
empirical assessment of pain beliefs.
Pain 36, 351358.
Worz, R., 2003. Pain in depression
depression in pain. Pain Clinical
Updates (IASP) XI (1), 14.
Worzer, W.E., Kishino, N.D.,
Gatchel, R.J., 2009. Primary,
secondary, and tertiary losses
in chronic pain patients.
Psychology, Injury, and Law 2,
215224.

48